Healthcare Provider Details

I. General information

NPI: 1780360297
Provider Name (Legal Business Name): KEYSTONE HEALTH LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 NIOBRARA AVE
HEMINGFORD NE
69348-9703
US

IV. Provider business mailing address

PO BOX 95
HEMINGFORD NE
69348-0095
US

V. Phone/Fax

Practice location:
  • Phone: 308-487-5922
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DAVID RANDOLPH
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 308-487-5922